Free-flap reconstruction has “generally good outcomes” in women aged 65 or older

Breast reconstruction using a “free flap” from the patient’s abdomen is a safe procedure with a high success rate in older women opting for reconstruction after mastectomy, reports a study in the December issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Although the risk of some complications is higher, free-flap reconstruction has “generally good outcomes” in women aged 65 or older, according to the report by ASPS Member Surgeon Oren Tessler, MD, MBA, and colleagues of Louisiana State University Health Sciences Center, New Orleans. “Older women desire breast reconstruction after mastectomy, and should be offered all reconstruction options available,” Dr. Tessler comments.

The researchers analyzed their experience with one type of free flap (deep inferior epigastric artery perforator, or “DIEP” flap) for breast reconstruction after mastectomy, comparing the outcomes in older versus younger women. Free flaps are an autologous reconstructive procedure, meaning that they use the patient’s own tissues (rather than implants). The DIEP flap uses tissue from the patient’s abdomen.

The study included data on DIEP flap reconstruction of 339 breasts in 208 patients after mastectomy for breast cancer between 2009 and 2013. Complications and risk factors were compared in a group of older women (average age 67 years, 54 flaps) versus younger women (average age 49 years, 285 flaps). The older women had substantially higher rates of medical risk factors, including diabetes, high blood pressure, and high cholesterol.

The primary outcome – complete or partial loss of the DIEP flap or the need for further flap surgery – was not significantly different between the older and younger groups. Dehiscence, a type of wound-healing complication, was more common in the older group: nearly 26 percent, compared to eight percent in the younger group. Complications related to the flap donor site in the abdomen were similar between age groups.

After adjustment for other factors – including the higher rate of medical risks in older women – age was a significant risk factor for complete flap loss as well as wound dehiscence. However, the absolute risk of complete flap loss was very low: only three cases (two in the older group, one in the younger) in a total of 339 DIEP flaps. Dr. Tessler comments, “The overall success rate in our older DIEP flap cases was 96.3 percent – only marginally lower than the 99.6 percent rate in our younger cases.”

Breast cancer is primarily a disease of older women: the median age at diagnosis is 62 years, and more than 40 percent of patients are 65 or older. Although breast reconstruction has important benefits after mastectomy, older women are less likely to undergo this procedure. Surgeons may perceive that breast reconstruction is riskier in older women, with higher rates of complications and wound healing problems.

While the new study does show that age 65 or older is associated with some increased risks after breast reconstruction. However, these complications appear at least partly related to the higher rates of medical risk factors among older women. The findings reinforce the importance of assessing the individual patient’s health status – not just age alone – in determining the risks of breast reconstruction.

Previous studies have suggested that older women undergoing mastectomy do want breast reconstruction, and that the benefits are similar to those in younger patients. “Therefore, we as plastic surgeons must be prepared to consult elderly patients before their mastectomies and be prepared to plan reconstructions in similar fashion to younger patients,” Dr. Tessler and coauthors write.

They conclude, “Although there is an increased risk of flap loss with age, patients 65 years and older can be advised that free flap reconstruction carries an acceptable risk profile in comparison to benefits of the procedure.”